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TRICARE Prime Coverage Details

Doctor and Patient
Doctor and Patient

TRICARE Prime is a health insurance program offered to active duty members, retirees, activated guard & reserve members, and families. If you're on active duty, you have to enroll in TRICARE Prime, all others can choose to enroll or use TRICARE Standard and Extra. TRICARE Prime offers fewer out-of-pocket costs than TRICARE Standard and Extra, but less freedom of choice for providers.

There are four TRICARE Prime Plans:

Each plan is generally the same, differing only in the geographical area that it covers. If you are a military member you MUST enroll in one of the TRICARE Prime Plans, you will have:

  • No out-of-pocket-costs
  • No enrollment fees
  • No network copayments
  • No point-of-service fees

Family members of Active Duty personnel will pay: 

  • Minimal out-of-pocket-costs
  • No enrollment fees
  • No network copayments
  • No point-of-service fees unless using the point-of-service option

All other people using TRICARE Prime will pay:

An annual enrollment fee of $282.60 for a single member and $565.20 for a family. You can pay these fees monthly, quarterly, or annually, the fees may increase every year. 

In addition to an enrollment fee, you also may pay a copayment for various services received at network providers, these fees are: 

TRICARE Prime Copayments
Service Cost
Annual Deductible $0 (unless using POS)
Ambulance Services $20 per occurance
Ambulatory Surgery (Same Day) $25
Behavioral Health (Inpatient) $40 per day
Behavioral Health (Outpatient) Individual: $25 / Group: $17
Clinical Preventive Services $0 from a network provider
DME, Prosthetic Devices, Medical Supplies Cost share is 20% of the negotiated fee
Emergency Services $30 per visit
Home Health Care $0
Hospice Care $0
Hospitalization (Inpatient Care) $11 per day ($25 minimum charge)
Immunizations $0 from a network provider
Laboratory & X-ray $0 for ancillary services* / $12 per visit for other radiology services
Maternity (office visits & hospitalization for delivery planned in a hospital in an inpatient setting) $11 per day ($25 minimum charge) 
Note: this is one global fee for all of the maternity care and delivery.
Maternity (office visits for delivery planning in a TRICARE-authorized birthing center) $25 per visit
Maternity (office visits for delivery planned at home or other setting) $12 per visit
Newborn Care $11 per day ($25 minimum charge)
Outpatient Visit $12 per visit
Skilled Nursing (Inpatient) $11 per day ($25 minimum charge)
*Ancillary services include:
  • Diagnostic radiology and ultrasound
  • Diagnostic nuclear medicine
  • Pathology and laboratory services
  • Cardiovascular studies
  • Venipuncture
  • Collection of blood samples
  • Fetal monitoring

Related Topics

TRICARE Insurance

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